Travel Health Advice for Resource-Limited Travelers

Introduction

Travelers seen in pre-travel clinic consultations often have financial constraints and must pay out of pocket for pre-travel care because many health insurance plans provide no or limited coverage for travel immunizations and prophylactic medications. Optimizing care for travelers without adequate insurance coverage or those with modest means can challenge the abilities of even the savviest travel medicine specialist. As an example, the estimated cost of a pre-travel consultation for a backpacker from the United States planning a 4-week trip to West Africa can exceed USD 1,000 for the initial consultation and vaccinations, excluding malaria prophylaxis. Since most travelers visiting friends and relatives receive their pre-travel evaluation in the primary care setting, healthcare professionals working in these settings with experience in travel medicine may be able to provide more affordable care compared to that in a dedicated travel medicine clinic.

Travelers on a limited budget might be at increased risk for travel-associated infections because they are more likely to visit remote areas, stay in more modest accommodations, and eat in restaurants or purchase food from other vendors with lower hygiene standards. However, the total cost of hospitalization, treatment, and lost wages after becoming ill with a vaccine- or prophylaxis-preventable disease can easily exceed the upfront cost of vaccination and prophylaxis, making the pre-travel consultation particularly important. Travelers also should consider the costs and benefits of purchasing travel health insurance and medical evacuation insurance before travel (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter).

Vaccines

Travelers and their healthcare professionals should check the Centers for Disease Control and Prevention (CDC) Travelers' Health website for the latest requirements and recommendations for their destinations.

Required vaccines

Only meningococcal (see Meningococcal Disease chapter) and yellow fever (see Yellow Fever chapter) vaccines are required categorically, and then only for some travelers: meningococcal vaccine for pilgrims traveling to the Kingdom of Saudi Arabia for the Hajj (see Saudi Arabia: Hajj and Umrah Pilgrimages chapter) and yellow fever vaccine for travelers to certain countries or arriving from certain countries, even if only in transit (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter). Administration and documentation of these vaccines should be prioritized because travelers without them could be denied entry to their destination. Travelers to polio-affected countries might be asked to show proof of polio vaccination before departure if their stay is >4 weeks (see Poliomyelitis chapter).

Routine vaccines

All travelers should be current with routine vaccines before international travel, regardless of destination. The benefits of routine vaccines extend beyond the travel period, and many provide lifelong immunity. Because these vaccines are part of scheduled national childhood and adult vaccination programs, associated costs generally are low, and many insurance companies reimburse the patient for the cost of administration. Travelers also can obtain these vaccines in a health department, primary care, or retail health setting, where costs might be lower than at a travel clinic.

For travelers who are not up to date with routine vaccines, prioritize administration of those that protect against diseases for which the traveler is most likely to be at risk (e.g., hepatitis A, influenza, or measles). Children in the United States routinely receive hepatitis A vaccine, but it is not included in the adult immunization schedule. Some travelers might be immune to diseases for which travel medicine specialists would consider immunization; pre-travel antibody testing might be covered by insurance when vaccines are not. Assess the time to departure to decide whether to test rather than vaccinate.

Recommended vaccines

When prioritizing recommended vaccines, consider time until departure, risk for disease at the destination, effectiveness and safety of the vaccine, and likelihood of future benefit because of repeat travel (see Vaccination and Immunoprophylaxis—General Principles chapter). For each traveler, weigh the potential severity of illness against the affordability and availability of immunization or prophylaxis, as well as the level of protection provided.

Cholera

Very few travelers are at risk for cholera, and vaccine cost is an important consideration. See the Cholera chapter for information on who may benefit from vaccination.

Chikungunya

Chikungunya vaccine is most appropriate for travelers heading to areas where there is an ongoing outbreak of disease. Because outbreaks are unpredictable, risk to travelers is low except during outbreak situations, and cost of the vaccine is likely to be borne by the traveler, this vaccine may not be a priority for most resource-limited travelers. See Chikungunya chapter, for information about indications for the chikungunya vaccine.

Coronavirus disease 2019

Healthcare professionals should discuss and recommend vaccination for COVID-19, regardless of destination (see COVID-19 chapter).

Hepatitis A and hepatitis B

Hepatitis A vaccine is not currently listed as a routine vaccine for U.S. adults, but this vaccine can provide lifelong immunity and healthcare professionals should consider administering it to any traveler not previously vaccinated (see Hepatitis A chapter). Hepatitis B vaccine is recommended for all U.S. adults under age 60 who have not been vaccinated and adults aged 60 years or older with risk factors for hepatitis B virus infection. Since hepatitis B acquisition is not frequently associated with travel, vaccination against hepatitis B might be a lower priority for travelers with limited resources, unless their destinations are areas of high disease incidence or they plan to engage in activities that place them at increased risk of exposure to blood-borne pathogens. As noted above, patients may encounter lower (or no) costs if they receive these vaccines in a health department, primary care, or retail health setting instead of a travel clinic.

Japanese encephalitis

Review the traveler's itinerary in detail to determine the need for Japanese encephalitis (JE) vaccine (see Japanese Encephalitis chapter). Some travelers might be able to obtain the single-dose JE vaccine, which is much less expensive and is available outside the United States, but bear in mind (and educate travelers about) issues surrounding quality of vaccines in many countries. Whether or not travelers receive the JE vaccine, provide instructions for when and how to use insect repellents and other measures to prevent mosquito bites (see Mosquitoes, Ticks, and Other Arthropods chapter).

Mpox

Mpox vaccine currently can be obtained free of cost and is often available in multiple settings (e.g., health departments, public health clinics, hospitals, and large social gatherings or venues). The mpox virus is transmitted to humans through close, sustained, physical contact with: someone who is infectious, contaminated materials from an infected individual, or infected animals (mammals, including rodents and non-human primates). The risk of mpox among travelers or humanitarian aid workers in endemic regions has not been studied, but vaccination can be offered to adults ≥18 years at higher risk for infection (see Sex and Travel chapter).

Rabies

When considering rabies vaccine for resource-limited travelers, factor in the risk for animal exposure, access to local health care, and availability of rabies immune globulin and rabies vaccine at the traveler's destination (see Rabies chapter) or CDC Rabies Status: Assessment by Country website. Rabies vaccination can be very costly in the United States, but for high-risk travelers, costs can be lessened with administration of the Advisory Committee on Immunization Practices–approved 2-dose pre-exposure series (previously 3 doses). Advise travelers who decline pre-exposure immunization to have a plan of action in case an exposure occurs. In many areas, rabies vaccine or rabies immune globulin are difficult or impossible to obtain, and travelers might need to be medically evacuated to receive proper post-exposure prophylaxis.

Tick-borne encephalitis

Travelers going to areas with tick-borne encephalitis virus-infected ticks and who anticipate tick exposure may consider this vaccine (see Tick-Borne Encephalitis chapter). Because the vaccination schedule takes a minimum of 6 months to complete, consideration may be given to obtaining additional doses abroad from reliable clinics in endemic areas.

Typhoid

Typhoid vaccine is approximately 50%–80% effective in preventing disease, and protection is not long-lasting (see Typhoid and Paratyphoid chapter). Thus, typhoid vaccine is critical for travelers to higher-risk destinations and to areas where typhoid is harder to treat because of multidrug resistance (e.g., Southeast Asia and the Indian subcontinent). Of note, development of optimal immunity after typhoid vaccine occurs approximately 1 week (oral vaccine) or 2 weeks (injectable vaccine) after administration, and thus it may not be cost-effective to give this vaccine to short-term travelers with an imminent departure. Recommendations for such travelers appear elsewhere (see Last-Minute Travelers chapter).

Other disease considerations

Malaria prophylaxis

Malaria risk varies depending on destination, accommodations, and activities during travel (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter). For a destination with malaria risk, chemoprophylaxis should always be provided, along with counseling on insect avoidance (see Malaria and Mosquitoes, Ticks, and Other Arthropods chapters). Costs associated with the different chemoprophylaxis regimens vary widely. Healthcare professionals should stay up to date on the cost of antimalarial medications in their region and at pharmacies so they can recommend the most cost-effective drug based on the traveler's planned itinerary (e.g., weekly-dosed malaria prophylaxis may be significantly less expensive than daily dosed for long-term travelers). If travelers ask whether they can purchase antimalarial drugs at their destination, advise them about the risk of inappropriate, substandard, and counterfeit medications and discourage them from this practice. Every pre-travel consultation should include detailed advice about preventing mosquito bites (see Mosquitoes, Ticks, and Other Arthropods chapter).

Travelers' diarrhea

Travelers' diarrhea is among the most common travel-related illnesses (see Travelers' Diarrhea chapter). Consider prescribing antibiotics to travelers for the self-treatment of moderate to severe diarrhea. Prophylaxis is rarely indicated and only in select patients at high risk for complications from travelers' diarrhea. Generic drugs may be obtained at low cost because only short courses (1–3 days) are prescribed. As with antimalarial drugs purchased at the destination, advise travelers about the risk of purchasing counterfeit antibiotics overseas.

Preventive behaviors

Educate all travelers about the importance of employing preventive behaviors that can reduce their exposure risks: wearing masks, avoiding animals, using insect bite precautions (see Mosquitoes, Ticks, and Other Arthropods chapter), following safe sex practices (see Sex and Travel chapter), washing their hands or using alcohol-based hand sanitizer frequently, and observing food and water precautions (see Food and Water Precautions for Travelers and Water Disinfection for Travelers chapters). Reassure travelers that the actions they take to protect themselves against vaccine-preventable diseases can also reduce their risk of other common conditions such as respiratory infections and diarrheal diseases.